Friday, August 12, 2011

Not long ago, during a yawn-inducing day of medical review lectures, a particular speaker threw a PowerPoint slide onto the screen with a three-part photo montage of a bottle of European-label wine, a suspiciously malodorous-appearing cheese, and a copper IUD.Underneath was a caption: “Three things that cost under $10 in France.”In the United States, a copper-based Paragard IUD will run you about $300 for the device…and another couple hundred – depending on the whims of your doctor – to have it gently placed in an orifice that will make it useful for preventing pregnancy.

Thirty-fold price difference for a device that essentially contains a few dimes’ worth of plastic and copper: there’s a lot to unpack here.

IUDs are not as popular in the US as they are in some other nations (in some parts of Europe, fully a quarter of the contracepting population uses IUDs; they are even more popular in Latin America and China). This is in no small part because of the experience of the Dalkon Shield, a largely innocent contraceptive device that was unfortunately strung up with a braided filament that tracked bacterial infections upward and resulted in enough deaths of otherwise young, healthy women that the whole branch of intrauterine contraception has never quite recovered an unbesmirched reputation.But the Dalkon Shield was largely an American product; other nations had little experience with such a toxic product, and have continued to use IUDs uninterrupted for decades.

So with a history of disaster like the Dalkon Shield, why should American women be at all interested in the IUD at all? The World Health Organization puts out a neat little chart of birth control methods in a hierarchy of effectiveness.You will note that effectiveness is largely a proxy for how often you have to think about the thing: if you have to consider your contraception every day (even worse, every time you start up a little foreplay), it falls down the chart.If you have to think about it once every few years, it rises up the chart.IUDs are up at the top of the effectiveness hierarchy because of the very human tendency to forget pills and condoms (and because IUDs happen to be rather effective products all on their own).In fact, IUDs and implantable devices like the Implanon (a reformulation of the failed Norplant of yesteryear) are the only reversible methods that make the WHO’s top tier. Pills are a notch beneath; condoms are even below that.

The barriers to finding the right form of birth control for the right individual can be immense, and many women default to the pill simply because it is what they know, hear about, ask about, or are given without any other discussion.Price is one issue: even out of pocket, IUDs are often cheaper than pills if used for the full five or ten years, but require a steep upfront investment that many women cannot afford (federal programs cover the copper – but not the hormonal – IUD for uninsured low-income women at this time).Many practitioners who feel comfortable handing out pills don’t know how to counsel on the risks and benefits of IUDs or implantable devices, much less place them.We can all cite a few providers out there who won’t give contraception to unmarried women, or women at all, or whatever variation of limitation one might set on women’s right to limit their fertility.There are providers who won’t insert IUDs in women who don’t have children yet, or who are still in their teen years (I argue the reverse: IUDs are perfect for teens, who have the highest failure rate for daily pills, who are most vulnerable to the later osteoporosis associated with the Depo Provera shot, and who benefit immensely from a span of years to finish high school and possibly college without interference from an unplanned pregnancy).

These are all culture-bound barriers, not medically-prescribed barriers. Even the edict against putting IUDs into women who have never born a child comes from a strange age: this language was inserted into the package literature of the copper IUD back in the days when the Dalkon Shield was causing infertility in its victims – the idea being that if you don’t have kids already, you should really have some first before you use a product that might cause you to become accidentally barren.There are so many things wrong with this line of thinking, I don’t think I need to enumerate them; and the relatively contraindication of putting IUDs in women without children has been removed from more recent versions of the package insert in deference to the fact that the Dalkon Shield has now been off the market for over 35 years.

But mostly, a failure to aggressively offer the most effective forms of birth control among all the options – and let a woman decide from the variety of methods available which is most right for herself - is in fact a failure to engage in the full protection of women’s health.Obama’s recent copay-free contraception edict is a promising one, but until the full breadth of choice exist, we are unlikely to see a significant change toward better fertility management and effective women’s health care across the board.

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